Step-2

Date of Birth

Leg pain, aching or cramping

Burning or itching of the skin

“Heavy” feeling in legs

Visible varicose or spider veins

Leg or ankle swelling, especially at the end of the day

Skin discoloration or texture changes, such as above the inner ankle

Open wounds or sores, such as above the inner ankle

Restless Leg Syndrome

Other (fill in the field below)